Rheumatologists ‘cannot be passive observers’ in combating ever-changing COVID-19
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SAN DIEGO — The SARS-CoV-2 virus continues to evolve, sometimes on a daily basis, thus making consensus difficult to achieve in terms of how to continue fighting against COVID-19 and its ever-increasing sequelae, said a speaker here.
However, addressing attendees at the Congress of Clinical Rheumatology West, Leonard Calabrese, DO, argued that rheumatologists are nonetheless uniquely positioned to continue that fight.
“The only thing that there is universal agreement on is that this is not going away,” he said. “Virtually everyone on the planet will get this disease at some point in time. That is almost incontrovertible.”
However, there is likely good news, according to Calabrese, who is RJ Fasenmyer chair of clinical immunology at the Cleveland Clinic, in that the trajectory of pathogenicity may continue to decrease.
“Omicron is a palpably less severe pathogen” than its predecessors, he said.
Calabrese urged vigilance among the rheumatology community, largely due to the vulnerability of the patient population.
“I predict there will be two epidemics: one of the vaccinated and the healthy and the other in the unvaccinated and immunocompromised,” he said, albeit the definition of “immunocompromised” in the COVID-19 setting remains unclear. “The CDC has not been very helpful in this regard. We must take it upon ourselves to sort this out.”
That said, one thing rheumatologists can do is ensure their patients continue to take medications for their rheumatic and autoimmune conditions regardless of how the virus is changing.
“Controlled disease is very important,” Calabrese said. “This is not the time to stop treating. Try to keep some balance.”
Vaccination should also be a priority for rheumatologists, particularly “boosting for those most vulnerable patients,” such as those treated with B-cell-depleting therapies such as rituximab (Rituxan, Genentech), he said.
This population in particular are “the same as unvaccinated” patients in terms of risk for COVID-19 infection, according to Calabrese.
“Regardless of data telling us that T cells are stimulated by these vaccines in B-cell-depleted patients, there is not a great deal of protection,” he said.
Rheumatologists can also educate their patients about the virus.
“A lot of people are frightened of COVID, but they are not educated about COVID,” Calabrese said.
According to Calabrese, education should focus on a plan of action for patients in the event they are exposed to COVID-19: who to call, when to call and what medications to take.
Although monoclonal antibodies such as tixagevimab plus cilgavimab, (Evusheld, AstraZeneca) and molnupiravir (Lagevrio, Merck) may be considered, pre-exposure or post-exposure prophylaxis is “not a substitute for vaccination,” he added.
Antiviral therapies such as nirmatrelvir/ritonavir (Paxlovid, Pfizer) also continue to play a critical role in the current phase of the pandemic.
“Antivirals are now the standard of care,” Calabrese said, noting that they can be “highly effective” in immunocompromised patients. “We must know how to counsel our patients and get them the right treatments at the right time.”
Regarding long COVID, Calabrese suggested that the clinical endotypes of chronic fatigue, brain fog, autonomic dysfunction, pain, fibromyalgia and neuropsychiatric outcomes are familiar to rheumatologists.
Some 50 syndromes and symptoms have been associated with long COVID, according to Calabrese.
“This is going to be around for the rest of our lives,” he said.
Because of the implications for autoimmunity, both COVID-19 and long COVID could be highly instructive for clinicians and researchers treating patients with rheumatic and autoimmune diseases.
“We are going to learn a lot about our diseases from this,” Calabrese said.
In the present, however, “We need to be involved in protecting our most vulnerable patients,” Calabrese said. “We cannot be passive observers.”
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Calabrese L. Role of the rheumatologist in COVID. Presented at The Congress of Clinical Rheumatology West; Oct. 20-23, 2022 (hybrid meeting).
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